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Download Oregon PTA Official Reflections Entry Form
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OREGON PTA REFLECTIONS PROGRAM OFFICIAL ENTRY FORM Directions: This form must be filled out, front and back, in its entirety, including the required signatures before submission. Please print clearly. Student’s Name: First ___________________________Middle Initial____ Last____________________ Address_____________________________________________________________________________ City____________________________________________ Zip plus 4____________________________ Phone________________________________ Email _________________________________________ School __________________________Grade _____ Age _____ Gender (circle) GRADE DIVISION (check one) Male or Female ART AREA (check one) ___ Primary (Preschool - 2) _______ Dance/choreography _______ Photography ___ Intermediate (3, 4 & 5) ___ Middle/Junior (6, 7 & 8) ___ Senior (9 - 12) _______ Film Production _______ Literature _______ Music Composition ___ Special Artist _______ Theatre ** _______ Visual Arts (includes 3D) ** denotes Oregon-specific category Title of Work - REQUIRED__________________________________________________________ Artist Statement - REQUIRED (min. one sentence. Max. - 100 words. Attach extra page, if necessary) ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ I grant Oregon PTA including Regions, Councils and Local PTA/PTSA Units, permission to use my work(s) for commercial or noncommercial use, including but not limited to public presentation of the work and reproduction of the work in print, electronic and multimedia format to promote the Reflections Program. Oregon PTA may continue to use my work as long as it has access to an archived copy. Oregon PTA is not responsible for lost or damaged works. Entries may not be returned. I understand that I must participate in the Reflections Program through a qualifying PTA/PTSA. I affirm that this is my own original work. I understand that the submission of my entry in the Reflections Program constitutes the above conditions. _____________________________________ ________________________________________ Student Signature Parent/legal guardian - REQUIRED if student is under 18 NOTE: Form continues on BACK. Form must be completed on both sides by entrant. To be completed by local PTA/PTSA Unit PTA/PTSA Name________________________________________ Council _____________ Region _______ Unit Address ______________________________________City_____________ Local Unit National PTA ID Number (8 Digits) Zip Plus 4 ______________ ____ ____ ____ ____ ____ ____ ____ ____ Local Unit Reflections Chair Name: ____________________________________________________________ Phone (______)__________-___________ Email ________________________________________________ Form revised July 2015 Page 1 ARTS CATEGORY SPECIFIC QUESTIONS Entrants must answer the following questions for the category relevant to their submission. Dance choreography What is the title of the dance music? ________________________________________________________________ Who is the performing artist or musical group? ________________________________________________________ Who is the composer? _____________________________ Who wrote the lyrics? ___________________________ Film Production What are the brand and model of the camera you used? ________________________________________________ If you used editing software, what kind did you use? ___________________________________________________ If you used background music, what is the title? _______________________________________________________ Who is the performing artist or musical group? ________________________________________________________ Who is the composer? _____________________________ Who wrote the lyrics? ___________________________ List the names of the people who appeared in this film _________________________________________________ _____________________________________________________________________________________________ Music Composition Are there singers? If so, how many and what are their names? __________________________________________ Are their instruments? If so, what instruments?_______________________________________________________ If you used music composition software, what kind did you use? _________________________________________ Photography What brand and model of camera did you use? _______________________________________________________ What kind of process did you use to prepare your photograph?___________________________________________ Dimensions of picture? _____________________ Dimension with matting (no frame) ________________________ Visual Arts including Three-Dimensional Visual Arts Describe the medium or type of visual art you developed (example - clay, fabric, wood). _____________________________________________________________________________________________ Dimensions of work? Height ___________ Width ____________ Length ____________ BE SURE TO COMPLETE BOTH SIDES OF THIS FORM CAREFULLY BEFORE SUBMITTING Form revised July 2015 Page 2
